Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis.

Establishing a multidisciplinary approach regarding the treatment of spondylodiscitis and analyzing its effect compared to a single discipline approach. 361 patients diagnosed with spondylodiscitis were included in this retrospective pre-post intervention study. The treatment strategy was either established by a single discipline approach (n = 149, year 2003-2011) or by a weekly multidisciplinary infections conference (n = 212, year 2013-2018) consisting of at least an orthopedic surgeon, medical microbiologist, infectious disease specialist and pathologist. Recorded data included the surgical and antibiotic strategy, complications leading to operative revision, recovered microorganisms, as well as the total length of hospital and intensive care unit stay. Compared to a single discipline approach, performing the multidisciplinary infections conference led to significant changes in anti-infective and surgical treatment strategies. Patients discussed in the conference showed significantly reduced days of total antibiotic treatment (66 ± 31 vs 104 ± 31, p < 0.001). Moreover, one stage procedures and open transpedicular screw placement were more frequently performed following multidisciplinary discussions, while there were less involved spinal segments in terms of internal fixation as well as an increased use of intervertebral cages instead of autologous bone graft (p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most frequently recovered organisms in both patient groups. No significant difference was found comparing inpatient complications between the two groups or the total in-hospital stay. Implementation of a weekly infections conference is an effective approach to introduce multidisciplinarity into spondylodiscitis management. These conferences significantly altered the treatment plan compared to a single discipline approach. Therefore, we highly recommend the implementation to optimize treatment modalities for patients.

Implementation of a multidisciplinary infections conference affects the treatment plan in prosthetic joint infections of the hip: a retrospective study.

INTRODUCTION: Establishing a systematic multidisciplinary approach in the treatment of prosthetic joint infections (PJI) of the hip and analyzing its effect on clinical decision-making. PATIENTS AND METHODS: Forty-six patients diagnosed with PJI of the hip were included in the retrospective study. The treatment plan was either established by a single-discipline approach (n = 20) or by a weekly multidisciplinary infections conference (n = 26) consisting of at least an orthopedic surgeon, microbiologist and pathologist. Recorded data included the length of hospital stay, number and type of surgeries, medical complications, recovered organisms as well as the number of applied antibiotics. RESULTS: Patients discussed in the multidisciplinary infections conference showed a significantly shorter in-hospital stay (29 vs 62 days; p < 0.05), a significant reduction in surgeries (1.8 vs 5.1; p < 0.05) and a smaller number of antibiotics required (2.8 vs 4.2; p < 0.05). No significant difference could be found comparing inpatient complications between the two groups. Staphylococcus aureus and coagulase-negative staphylococci were the most frequently recovered organisms in both patient groups. CONCLUSION: This study demonstrates the successful implementation of a weekly infections conference as an instrument to introduce a multidisciplinary approach to PJI of the hip. Implementation of these conferences significantly improves the treatment plan compared to a single-discipline approach, which we therefore highly recommend for other institutions. Multidiscipline may even affect clinical outcome which needs to be further investigated.

[Fine-needle aspiration (FNA) of the thyroid gland : Analysis of discrepancies between cytological and histological diagnoses]. / Feinnadelaspiration (FNA) der Schilddrüse : Analyse diskrepanter zytologischer und histologischer Diagnosen.

BACKGROUND: Diagnostic problems of thyroid cytology are frequently discussed, but relevance and causes of discrepant cytological and histological diagnoses are rarely studied in detail. OBJECTIVES: Investigation of causes and relevance of discrepant diagnoses. MATERIALS AND METHOD: The analysis includes 297 patients who had thyroid resection after prior fine needle aspiration (FNA) and is based on the cytological and histological reports. In special cases, cytological and histological specimens were re-examined. RESULTS: Malignant tumors were found in 45 patients (15.1 %). In 5 patients the cytological diagnosis was "false negative". Three of these 5 tumors were papillary carcinomas (PTC) of ≤10 mm, one an obviously nonmalignant papillary proliferation of the thyroidal epithelium and one a malignant lymphoma complicating autoimmune thyreoiditis (AIT). In 11 of the 35 patients with a FNA diagnosis "suspicious of malignancy" or "malignant," 1 AIT, 4 goiter nodules, and 6 adenomas were diagnosed histologically. However, since distinct nuclear atypia was found in three of five false positive diagnoses, there still remains doubt in their benignity. CONCLUSIONS: Carcinomas of ≤10 mm incidentally detected in the resected thyroid tissue may not be relevant to the patient and do not reduce the high negative predictive value of FNA. The final diagnosis on the resected tissue should include the cytological findings. Discrepant findings should be commented in the report to the clinician.

[Intramuscular myxoma of the lower leg]. / Intramuskuläres Myxom des Unterschenkels.

The intramuscular myxoma is a rare benign soft tissue tumor characterized by bland spindle-shaped and stellate cells embedded in hypovascular myxoid stroma. We report the isolated case of a 44-year-old female patient with an intramuscular myxoma in the anterior tibial muscle and report the clinical and radiographic findings. We performed an analysis of the GNAS gene mutation status with a positive finding. In difficult cases, recurrent tumors or small biopsies detection of a GNAS mutation can be useful to confirm the diagnosis of an intramuscular myxoma.

Losses at chromosome 4q are associated with poor survival in operable ductal pancreatic adenocarcinoma.

Here we tested the prognostic impact of genomic alterations in operable localized pancreatic ductal adenocarcinoma (PDAC). Fifty-two formalin-fixed and paraffin-embedded primary PDAC were laser micro-dissected and were investigated by comparative genomic hybridization after whole genome amplification using an adapter-linker PCR. Chromosomal gains and losses were correlated to clinico-pathological parameters and clinical follow-up data. The most frequent aberration was loss on chromosome 17p (65%) while the most frequent gains were detected at 2q (41%) and 8q (41%), respectively. The concomitant occurrence of losses at 9p and 17p was found to be statistically significant. Higher rates of chromosomal losses were associated with a more advanced primary tumor stage and losses at 9p and 18q were significantly associated with presence of lymphatic metastasis (chi-square: p = 0.03, p = 0.05, respectively). Deletions on chromosome 4 were of prognostic significance for overall survival and tumor recurrence (Cox-multivariate analysis: p = 0.026 and p = 0.021, respectively). In conclusion our data suggest the common alterations at chromosome 8q, 9p, 17p and 18q as well as the prognostic relevant deletions on chromosome 4q as relevant for PDAC progression. Our comprehensive data from 52 PDAC should provide a basis for future studies with a higher resolution to discover the relevant genes located within the chromosomal aberrations identified.

Loss of prestin does not alter the development of auditory cortical dendritic spines.

Disturbance of sensory input during development can have disastrous effects on the development of sensory cortical areas. To examine how moderate perturbations of hearing can impact the development of primary auditory cortex, we examined markers of excitatory synapses in mice who lacked prestin, a protein responsible for somatic electromotility of cochlear outer hair cells. While auditory brain stem responses of these mice show an approximately 40 dB increase in threshold, we found that loss of prestin produced no changes in spine density or morphological characteristics on apical dendrites of cortical layer 5 pyramidal neurons. PSD-95 immunostaining also showed no changes in overall excitatory synapse density. Surprisingly, behavioral assessments of auditory function using the acoustic startle response showed only modest changes in prestin KO animals. These results suggest that moderate developmental hearing deficits produce minor changes in the excitatory connectivity of layer 5 neurons of primary auditory cortex and surprisingly mild auditory behavioral deficits in the startle response.

Simultaneous tumour-like, atypical basal cell hyperplasia and acinar adenocarcinoma of the prostate: a comparative morphological and genetic approach.

Basal cell tumours of the prostatic gland are rare, and the classification is difficult. In the present case report, a large, tumour-like proliferation of atypical basaloid cells was found incidentally in a prostatectomy specimen that otherwise contained a conventional acinar adenocarcinoma. The basaloid cells displayed a solid or adenoid-cystic growth pattern and strongly expressed high-molecular-weight cytokeratins and bcl-2. A high Ki-67 index was recorded within the atypical basaloid cells, by far exceeding the one counted in the conventional adenocarcinoma. However, there were no definite criteria for a malignant behaviour of the basal cell tumour. Comparative genomic hybridisation from microdissected tumour cells yielded losses at the short arms of chromosomes 8 and 12 in the conventional adenocarcinoma and a normal karyotype in the basal cell tumour. The pathological findings favoured the diagnosis of an atypical basal cell hyperplasia.

A modified adenovirus can transfect cochlear hair cells in vivo without compromising cochlear function.

The loss of cochlear hair cells, or the loss of their capacity to transduce acoustic signals, is believed to be the underlying mechanism in many forms of hearing loss. To develop viral vectors that allow for the introduction of genes directly into the cochleae of adult animals, replication-deficient (E1(-), E3(-)) and replication-defective (E1(-), E3(-), pol(-)) adenovirus vectors were used to transduce the bacterial beta-galactosidase gene into the hair cells of the guinea pig cochlea in vivo. Distortion product otoacoustic emissions, which monitor the functional status of outer hair cells, were measured throughout the viral infection periods to identify hair cell ototoxicity. The results demonstrated that the use of the (E1(-), E3(-)) adenovirus vectors containing CMV-driven LacZ, compromised cochlear function when gradually introduced into scala tympani via an osmotic pump. However, when (E1(-), E3(-), pol(-)) adenoviral vectors containing CMV-driven LacZ were used to transduce cochlear hair cells, there was no loss of cochlear function over the frequency regions tested, and beta-galactosidase (beta-gal) was detected in over 80% of all hair cells. Development of a viral vector that infects cochlear hair cells without virus-induced ototoxic effects is crucial for gene replacement strategies to treat certain forms of inherited deafness and for otoprotective strategies to prevent hair cell losses to treat progressive hearing disorders. Moreover, in vivo (E1(-), E3(-), pol(-)) adenovirus mediated gene-transfer techniques applied to adult guinea pig cochleae may be useful in testing several hypotheses concerning what roles specific genes play in normal cochlear function.

Cochlear function and transgene expression in the guinea pig cochlea, using adenovirus- and adeno-associated virus-directed gene transfer.

Development of a viral vector that can infect hair cells of the cochlea without producing viral-associated ototoxic effects is crucial for utilizing gene replacement therapy as a treatment for certain forms of hereditary deafness. In the present study, cochlear function was monitored using distortion-product otoacoustic emissions (DPOAEs) in guinea pigs that received infusions of either (E1(-), E3(-)) adenovirus, or adeno-associated virus (AAV), directly into the scala tympani. Replication-deficient (E1(-), E3(-)) adenovirus-directed gene transfer, using the cytomegalovirus (CMV) promoter, drove transgene expression to inner hair cells and pillar cells of the cochlea. AAV transduction was tested with several promoters, such as platelet-derived growth factor (PDGF), neuron-specific enolase (NSE), and elongation factor 1alpha (EF-1alpha) promoters; which drove transgene expression to cochlear blood vessels, nerve fibers, and certain spiral limbus cells, respectively. AAV transgene expression was visualized by green fluorescent protein immunostaining. Immunocytochemistry to heparan sulfate confirmed the absence of proteoglycans in guinea pig hair cells, indicating that the receptor for AAV was not present on these cells. However, the heparan sulfate proteoglycan expression pattern mimicked the AAV transduction pattern. An overall finding was that cochlear function was not altered throughout the infection period using AAV titers as high as 5 x 10(8) IP/infused cochlea. In contrast, cochlear function was severely compromised by 8 days postinfection with adenoviral titers of 5 x 10(8) PFU/infused cochlea, and outer hair cells were eliminated. Thus, cochlear hair cells are amenable to in vivo gene transfer using a replication-deficient (E1(-), E3(-)) adenovirus. However, replication-defective or gutted adenovirus vectors must be employed to overcome the ototoxic effects of (E1(-), E3(-)) adenovirus vectors.

Temporary and permanent noise-induced changes in distortion product otoacoustic emissions in CBA/CaJ mice.

A number of studies have shown that the ear can be protected from sound over-exposure, either by activating the cochlear efferent system, or by sound 'conditioning' in which the role of the efferent system is less certain. To study more definitively the molecular basis of deliberately induced cochlear protection from excessive sounds, it is advantageous to determine, for an inbred mouse strain, a range of noise exposure parameters that effectively alter cochlear function. As an initial step towards this goal, young CBA/CaJ mice were exposed to a 105-dB SPL octave-band noise (OBN), centered at 10 kHz, for various lengths of time consisting of 10 min, or 0.5, 1, 3, or 6 h. Distortion product otoacoustic emissions (DPOAEs) at the 2f1-f2 frequency, in response to equilevel primary tones of low to moderate levels, were used to quantify the damaging effects of these sound over-exposures on cochlear function. In addition, staining for acetylcholinesterase (AChE) activity to assess for noise-induced changes in the pattern of efferent-nerve innervation to the cochlea was also performed in a subset of mice that were exposed to the longest-lasting 6-h OBN. The 10-min OBN resulted in only temporary reductions in DPOAE levels, which recovered to pre-exposure values within 5 days. Increasing the exposure to 0.5 h resulted in permanent DPOAE losses that, for low primary-tone levels, were still present at 31 days post-exposure. Additionally, the 1-h and longer exposures caused permanent reductions in DPOAEs for all test levels, which were measurable at 31 days following exposure. Light-microscopic observations restricted to the 11-18-kHz frequency region of the organ of Corti, for a subset of mice exposed to the 6-h OBN, uncovered a significant loss of outer hair cells (OHCs). However, despite the OHC loss in this region, the AChE activity associated with the related pattern of efferent innervation remained largely intact.

Cloning and expression of the alpha9 nicotinic acetylcholine receptor subunit in cochlear hair cells of the chick.

Hair cells of the vertebrate inner ear are subject to efferent control by the release of acetylcholine (ACh) from brainstem neurons. While ACh ultimately causes the hair cell to hyperpolarize through the activation of small conductance Ca(2+)-activated K(+) channels, the initial effect is to open a ligand-gated cation channel that briefly depolarizes the hair cell. The hair cell's ligand-gated cation channel has unusual pharmacology that is well matched to that of the nicotinic subunit alpha9 expressed in Xenopus oocytes. We used sequence-specific amplification to identify the ortholog of alpha9 in the chick's cochlea (basilar papilla). Chick alpha9 is 73% identical to rat alpha9 at the amino acid level. A second transcript was identified that differed by the loss of 132 base pairs coding for 44 amino acids near the putative ligand-binding site. RT-PCR on whole cochlear ducts suggested that this short variant is less abundant than the full length alpha9 mRNA. In situ hybridization revealed alpha9 mRNA in sensory hair cells of the chick cochlea. The pattern of expression was consistent with the efferent innervation pattern. The alpha9 label was strongest in short (outer) hair cells on which large calyciform efferent endings are found. Tall (inner) hair cells receiving little or no efferent innervation had substantially less label. The cochlear ganglion neurons were not labeled, consistent with the absence of axo-dendritic efferent innervation in birds. These findings suggest that alpha9 contributes to the ACh receptor of avian hair cells and supports the generality of this hypothesis among all vertebrates.

Evaluation of an alternative radiochemical purity testing method for technetium-99m sestamibi.

OBJECTIVE: Our study evaluated the accuracy and reliability of 3 radiochemical purity (RCP) measurement methods of 99mTc-sestamibi. A regular-sized (1.0 cm x 9.0 cm) Whatman 31 ET Chr paper strip (regular 31 ET) also was included in our evaluation because of its ease in handling. METHODS: The miniaturized and regular 31 ET methods were compared with the standard RCP testing method (aluminum oxide-coated plastic thin-layer chromatography [TLC] plate, with > or = 95% ethanol as the developing solvent). A total of 30 experimental runs were performed in triplicate (n = 90) over an RCP range of 82%-98%. The 99mTc-sestamibi preparations were reconstituted purposely to ensure that 50% of the tested samples had RCP values below the 90% limit. RESULTS: The evaluated RCP ranges were 89.9% +/- 6.3%, 91.0% +/- 3.8%, and 91.4% +/- 4.3% for the TLC, miniature 31 ET, and regular 31 ET methods, respectively (n = 30 each). A strong correlation was found between the TLC and miniature 31 ET methods (r = 0.92), as well as between the TLC and regular 31 ET methods (r = 0.94). Both alternative methods tended to overestimate RCP value as determined by the TLC method, especially in an RCP range below 95%. This resulted in a false-positive rate of 27% for the miniature 31 ET method and 33% for the regular 31 ET method. The test/retest reliability was 99% for both the TLC and regular 31 ET methods, and 91% for the TLC and miniature 31 ET methods. CONCLUSION: The miniature and regular 31 ET methods produced a high false-positive rate, which makes them unacceptable for the determination of RCP value of 99mTc-sestamibi.

Isolation of a cDNA encoding a Kex2-like endoprotease with homology to furin from the nematode Caenorhabditis elegans.

A cDNA was isolated from the nematode Caenorhabditis elegans that encodes an endoprotease which is a member of the Kex2 family of serine endoproteases. Degenerate oligonucleotide primers were designed based on conserved regions within the active sites of known Kex2-like endoproteases, and were used for reverse transcription-polymerase chain reaction (RT-PCR) of poly(A)+RNA isolated from C. elegans. A PCR product was isolated that had homology to the active sites of known furin endoproteases, and was used as a probe to screen a C. elegans cDNA library. A Kex2-like endoprotease (CelfurPC) which encoded a 692-amino-acid pre-proendoprotease, was identified. The deduced amino acid sequence for the catalytic domain of CelfurPC is homologous to the known Kex2-like endoproteases, with strongest structural homology to the furin/PACE4 family. However, all furins and PACE4 proteins contain a characteristic cysteine-rich domain, and all furins contain a transmembrane domain, neither of which is present in the CelfurPC protein. CelfurPC may thus represent a new class of Kex2-like endoprotease.

Identification of a pore lining segment in gap junction hemichannels.

The ability of certain connexins to form open hemichannels has been exploited to study the pore structure of gap junction (hemi)channels. Cysteine scanning mutagenesis was applied to cx46 and to a chimeric connexin, cx32E(1)43, which both form patent hemichannels when expressed in Xenopus oocytes. The thiol reagent maleimido-butyryl-biocytin was used to probe 12 cysteine replacement mutants in the first transmembrane segment and two in the amino-terminal segment. Maleimido-butyryl-biocytin was found to inhibit channel activity with cysteines in two equivalent positions in both connexins: I33C and M34C in cx32E(1)43 and I34C and L35C in cx46. These two positions in the first transmembrane segment are thus accessible from the extracellular space and consequently appear to contribute to the pore lining. The data also suggest that the pore structure is complex and may involve more than one transmembrane segment.

Identification of a protein that confers calcitonin gene-related peptide responsiveness to oocytes by using a cystic fibrosis transmembrane conductance regulator assay.

An expression-cloning strategy was used to isolate a cDNA that encodes a protein that confers calcitonin gene-related peptide (CGRP) responsiveness to Xenopus laevis oocytes. A guinea pig organ of Corti (the mammalian hearing organ) cDNA library was screened by using an assay based on the cystic fibrosis transmembrane conductance regulator (CFTR). The CFTR is a chloride channel that is activated upon phosphorylation; this channel activity was used as a sensor for CGRP-induced activation of intracellular kinases. A cDNA library from guinea pig organ of Corti was screened by using this oocyte-CFTR assay. A cDNA was identified that contained an open reading frame coding for a small hydrophilic protein that is presumed to be either a CGRP receptor or a component of a CGRP receptor complex. This CGRP receptor component protein confers CGRP-specific activation to the CFTR assay, as no activation was detected upon application of calcitonin, amylin, neuropeptide Y, vasoactive intestinal peptide, or beta-endorphin. In situ hybridization demonstrated that the CGRP receptor component protein is expressed in outer hair cells of the organ of Corti and is colocalized with CGRP-containing efferent nerve terminals.

In situ hybridization reveals transient laminin B-chain expression by individual glial and muscle cells in embryonic leech central nervous system.

Laminin, which strongly stimulates axon outgrowth in vitro, appears transiently within the central nervous system (CNS) in embryos. After CNS injury, laminin reportedly reappears along axonal pathways only in animal species in which central axon regeneration is successful, including the leech Hirudo medicinalis. Although glia have been suspected of making CNS laminin, in adult leeches glia are not required for laminin synthesis and evidently microglia, not present in the early embryo, produce laminin. To determine which embryonic cells make laminin, a 1.2 kb DNA fragment of leech laminin B1 chain, with homology to Drosophila, human, and mouse B1 laminins and rat S laminin, was isolated using reverse-transcription and degenerate polymerase chain reaction (PCR) cloning. In situ hybridization revealed that laminin expression began before embryonic day 8, and by days 8 and 9 it was seen in paired CNS muscle cells. By late day 9, the two neuropil glial cells began to express laminin. Lucifer Yellow dye was injected intracellularly and muscle cells stimulated to contract, confirming the identities of muscle and glial cells. Packet glial cells began to express B1 laminin by embryonic day 12. By day 15, the cells of the perineurial sheath expressed B1 laminin, whereas it was no longer detectable in CNS muscle and glia. The results agree with published immunohistochemistry showing laminin within the CNS among growing axons by day 8, and only later in the perineurial sheath, by which time laminin disappears from within the CNS. Therefore, different cells synthesize laminin in the embryo and during repair in adults.

Gain changes of the cat's vestibulo-ocular reflex after flocculus deactivation.

Motor learning can be demonstrated in the vestibulo-ocular reflex (VOR) by changing its gain (eye velocity/head velocity) with goggles and optokinetic (OK) drums. It is known that the flocculus is essential for this plasticity but there is controversy about whether the modifiable synapses mainly responsible are in the flocculus. To investigate this further we utilized the known reciprocal relationship between complex spikes and simple spikes in Purkinje cell discharges. By stimulating climbing fibers from the olive to the flocculus at 7 Hz, the simple spike rate of almost all recorded floccular cells could be driven to zero. This was termed floccular shutdown and it felt to effect a functional, reversible flocculectomy. Sixty single units in the flocculi of four cats were recorded. Stimulation of the climbing fibers at 7 Hz caused the discharge rate to decrease to zero in 95% of these cells. The gain of the horizontal VOR in three cats was driven repeatedly to twice or half its normal value by rotation within a moving OK drum and also by wearing magnifying or fixed-field goggles; this process required 3 days. If, on the 4th day, the cat was exposed to an OK drum rotating in the opposite direction, the gain was driven back to normal in 30 min. If, however, the climbing fibers were stimulated at 7 Hz during these 30 min, the gain did not return--learning was blocked. This verified that loss of floccular activity by this method abolishes VOR gain plasticity. Moreover, when 7 Hz stimulation first began, after 3 days of adaptation, the adapted gain remained at its adapted value, either half or twice normal, even in the face of floccular shutdown. This result appears incompatible with the hypothesis that the modifiable synapses are in the flocculus.

Phoria adaptation in patients with cerebellar dysfunction.

The authors studied phoria adaptation to horizontal base-out prism in 17 patients with well-documented cerebellar lesions. There was no significant difference between mean adaptation measured in the patients and ten normal controls. Individually, normal adaptation was found in 12 patients. Abnormal adaptation was found in five patients, all but one of which had other neurologic lesions. These results suggest that phoria adaptation to base-out prism is not diminished by a cerebellar lesion unless it is accompanied by another nervous system lesion(s).